A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?
An assistive personnel is encouraging intake of oral fluids.
Supplemental oxygen is in use.
Benzodiazepines are administered every 4 hr.
A family member remains at the client's bedside 24 hr each day.
The Correct Answer is A
A. An assistive personnel is encouraging intake of oral fluids: For a client in the active dying phase, forcing or encouraging oral intake can cause discomfort, aspiration, or fluid overload. The focus should be on comfort rather than meeting standard hydration goals, so this requires intervention by the nurse.
B. Supplemental oxygen is in use: Oxygen may be provided for comfort if the client experiences dyspnea. Its use in the active dying phase is appropriate and does not require intervention unless it causes discomfort or is unnecessary.
C. Benzodiazepines are administered every 4 hr: Scheduled benzodiazepines can help manage anxiety, restlessness, or dyspnea in a dying client. This is an appropriate intervention for comfort and does not require nurse intervention.
D. A family member remains at the client's bedside 24 hr each day: Continuous presence of family provides emotional support and comfort for both the client and loved ones. This is consistent with hospice care principles and does not require nurse intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. pH 7.48, PaCO₂ 32 mm Hg, HCO₃ 24 mEq/L: The elevated pH indicates alkalosis, but HCO₃ is within normal limits. This pattern suggests respiratory alkalosis with compensatory changes rather than metabolic alkalosis.
B. pH 7.36, PaCO₂ 38 mm Hg, HCO₃ 25 mEq/L: These values are within normal limits, indicating acid-base balance. They do not reflect metabolic alkalosis and would not explain clinical signs of alkalemia.
C. pH 7.46, PaCO₂ 36 mm Hg, HCO₃ 29 mEq/L: The elevated pH indicates alkalosis, and the increased HCO₃ identifies a metabolic origin. The PaCO₂ is near normal, suggesting minimal respiratory compensation, which is consistent with metabolic alkalosis.
D. pH 7.26, PaCO₂ 35 mm Hg, HCO₃ 18 mEq/L: The low pH and low HCO₃ indicate metabolic acidosis, not alkalosis. These values are inconsistent with the expected findings for metabolic alkalosis.
Correct Answer is B
Explanation
A. Sleeps 8 to 10 hr per night: Adequate sleep does not increase the risk of injury; in fact, it supports overall health and healing. Sleep patterns are not directly related to bleeding or bruising risk in thrombocytopenia.
B. Uses a firm bristled toothbrush: A firm bristled toothbrush can cause trauma to the gums, leading to bleeding in clients with low platelet counts. Using a soft-bristled toothbrush helps minimize mucosal injury and reduces the risk of hemorrhage.
C. Increased intake of green leafy vegetables: Green leafy vegetables are high in vitamin K, which supports clotting. While dietary vitamin K can influence coagulation, it does not increase injury risk; it may actually help maintain hemostasis.
D. Wears a face mask around others: Wearing a mask reduces the risk of infection, which is important but does not directly affect bleeding or injury risk. Infection prevention is beneficial but not a factor that increases susceptibility to trauma in thrombocytopenia.
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